Government of Tamil Nadu TENDER DOCUMENT TO SELECT INSURANCE COMPANY TO IMPLEMENT The Chief Minister s Comprehensive Health Insurance Scheme

Transcription

1 Government of Tamil Nadu TENDER DOCUMENT TO SELECT INSURANCE COMPANY TO IMPLEMENT The Chief Minister s Comprehensive Health Insurance Scheme Invitation of Bid - The Government of Tamil Nadu has decided through G.O. (Ms)No.169,H&FW (EAP-II(2)) Department, Dated to launch the Chief Minister s Comprehensive Health Insurance Scheme to achieve the objective of providing quality health care to the people of Tamil Nadu. As per the G.O.(Ms) No.189/H&FW (EAP-II(2)) Dept., dated and G.O.(Ms) No.275/H&FW (EAP-II(2)) Dept., dated , this tender invited for selecting the Public Sector insurance partner for implementing the scheme. 1. DEFINITIONS: In this tender document unless the context otherwise provides (a) Scheme means, the Chief Minister s Comprehensive Health Insurance Scheme as per G.O. (Ms) No.169 H&FW (EAP-II (2)) Department, Dated and amendments thereto (Enclosure 1) (b) Guidelines means the Chief Minister s Comprehensive Health Insurance Scheme Guidelines, 2011, which is given in Enclosure -2. (c) Tender Accepting Authority means, the State Empowered Committee constituted by the Government of Tamil Nadu as per G.O. (Ms)No.169 H&FW (EAP-II (2)) Department, Dated and amendments thereto (Enclosure 1). (d) Tender Inviting Authority means, Project Director, Tamil Nadu Health Systems Society, Chennai (e) Words and expressions used but not defined in this document, but defined in the Tamil Nadu Transparency in Tenders Act, 1998 & Rules, 2000 framed there under (Tamil Nadu Act Number 43 of 1998), the Scheme or the Guidelines shall have the same 1

2 meanings respectively assigned to them in that Act, the Scheme or the Guidelines, as the case may be. 2. SUBMISSION OF BIDS By virtue of the provisions contained in the Tamil Nadu Transparency in Tenders Act, 1998 (Tamil Nadu Act Number 43 of 1998) and the Rules, 2000, framed there under, the Project Director, Tamil Nadu Health Systems Society seeks detailed bids from Public Sector Insurance Companies interested in implementing the Scheme, as detailed in the Scheme and the Guidelines. The proposed document should include the following: SECTION A TECHNICAL BID: QUALIFYING CRITERIA: (i) The bidder should be a Public Sector Insurance Company authorized to conduct the business of Health Insurance by the Insurance Regulatory and Development Authority (IRDA). Copy of IRDA license to conduct health insurance business, attested by a Notary Public or by a Group A or B Officer of the Central Government or State Government shall be enclosed. (ii) The Bidder should submit the proof of being a Public Sector Insurance Company. (iii) The Bidder should have been licensed for doing Health Insurance for at least one year as on the last date for submission of bid and should have at any one point of time in last three years, reckoned from the last date for bid submission, live health insurance policies covering at least 2.5 lakhs families / individual policies in aggregate. (iv) The Bidder should not have been banned or debarred by any State Government / Central Government or its Agencies or not qualified in participating the Government Schemes as per the IRDA Guidelines for any issue, and the ban or debarment should not be in currency on the last date for submission of bid. The Bidder should give an 2

3 undertaking on this. The Bidder who has been banned or debarred even after submission of bids but before entering in to the agreement, shall not be considered. Explanation: It is clarified that a ban which is not in currency on the last date for submission of bid would not be deemed to be a bar on the company from bidding. (v) Bidders eligible as per above conditions, are not permitted to bid by forming consortium with other insurance companies. (vi) The successful bidder should complete the performance obligations listed out in the activity chart as per Annexure - A of the Guidelines. (vii) The Third Party Administrator, if any, implementing the scheme on behalf of the successful bidder should also be an agency approved by the Insurance Regulatory and Development Authority. The successful bidder would be required to establish the offices, within one month of signing the agreement, for processing claims in all districts of Tamil Nadu. The details of Third party Administrator(s), if any, or branches of the successful bidder shall be furnished within one month from the date of signing the agreement. (viii) The successful Bidder would be required to have, within one month of signing of the Agreement, an accredited hospital network in all districts of the State of Tamil Nadu and other places as may be designated by The Project Director, Tamil Nadu Health Systems Society. The yardstick prescribed under Clause 8 of the Guidelines shall be adhered to by the successful Bidder while accrediting the hospitals. The details of the Hospitals covered under the Scheme shall be furnished in the format in Annexure - B to the Guidelines within one month of the execution of agreement and to be updated on monthly basis. 3

4 SECTION B FINANCIAL BID i. The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary as defined in the Scope of the Scheme under clause 5 of the Guidelines. ii. The coverage will be up to Rs. 1 lakh / per family per year as per Annexure C, with provision to pay upto Rs 1.5 lakhs per year per family for certain specified procedures as per Annexure D and follow up services as per Annexure E and Diagnostic services as per Annexure F to the Guidelines, in any of the empanelled hospitals subject to package rates on cashless basis through Health insurance card or Ration Card. iii. The benefit will be on floater basis and can be availed of individually or collectively by members of the family during the policy year with no restriction on the number of times the benefit is availed. The unutilized Entitlement will lapse at the end of every policy year. iv. The service tax due on the total premium from time to time will be borne by the Tamil Nadu Health Systems Society. v. The details of the financial bid shall be furnished in the format prescribed in Enclosure-3. vi. The Health Insurance Identity card cost shall be separated from the premium amount and the card cost is fixed at Rs. 50/-. This cost will be paid to the Public Sector insurance company on receipt of acknowledgment and verification of the distribution of the cards to the beneficiaries. 3. CONTENT OF BID i. Technical bid shall contain the following documents: a. Attested Copy of IRDA License b. Proof of being a Public Sector Insurance Company. c. Proof of covering a minimum 2.5 lakhs families / individual policies in aggregate at any point of time in the last three years.(copy of the policy, reflection of the policy details in the balance sheet or annual statement or IRDA journal and 4

5 certification by the company auditor to be submitted as evidence) d. Declaration from the insurer that the Public Sector Insurance Agency has not been banned /debarred by any State Government/Central Government or its Agencies or not disqualified in participating the Government schemes as per IRDA guidelines. e. An undertaking that they have submitted their Bid as a single entity only and have not formed a Consortium for the scheme. f. Company shall submit the details of present office infrastructure in the state with organogram. g. Proposed Activity Chart with time lines as per Annexure A of the Guidelines. h. Any Other information. ii. The Envelope containing the technical bid shall be marked in bold as SECTION A - TECHNICAL BID FOR IMPLEMENTING CHIEF MINISTER S COMPREHENSIVE HEALTH INSURANCE SCHEME, written on the top of the envelope. iii. Financial bid should be sealed in another envelop clearly marked in bold as SECTION B - FINANCIAL BID FOR IMPLEMENTING THE CHIEF MINISTER S COMPREHENSIVE HEALTH INSURANCE SCHEME, written on the top of the envelope. iv. Both the envelopes should have the Bidder s Name and Address clearly written at the Left Bottom Corner of the envelope. v. Both the envelopes should be put in a larger cover / envelope, sealed and clearly marked in BOLD letters:- 5

6 TECHNICAL BID AND FINANCIAL BID FOR THE CHIEF MINISTER S COMPREHENSIVE HEALTH INSURANCE SCHEME, written on envelope and have the Bidder s Name and Address clearly written in BOLD at the Left Bottom Corner. vi. Tenders shall remain valid for 90 (ninety) days after the deadline for submission of tender. A tender valid for a shorter period will be rejected. In exceptional circumstances, prior to the expiry of the original time limit, the bidders consent may be solicited for an extension of the period of validity. The request and the responses thereto shall be made in writing. vii. The bid may be rejected. (a) if the bidder fails to clearly mention Technical or Financial Bid on the respective envelopes: (b) if the envelope is not properly sealed. (c) if both envelopes i.e. Financial Bid and Technical Bid are not submitted in separate covers together kept in large envelope. (d) if any details related to the financial bid are mentioned in technical bid. 4. SIGNATURE ON EACH PAGE OF DOCUMENT: The competent authority of the bidder must sign and put official stamp on each page of bid. If any page is unsigned it may lead to rejection of the bid. 5. AMENDMENTS TO TENDER DOCUMENTS:- (a) At any time after the issue of tender documents and before the opening of the tender, the Tender Inviting Authority may make any changes, modifications or amendments to the tender 6

7 documents and shall sent intimation of such changes to all those who have purchased the original tender documents and upload corrigendum for the information of those who have downloaded the tender documents from the website. (b) In case any one Bidder asks for a clarification to the tender documents before 48 hours of the opening of the tender, the tender inviting authority shall ensure that a reply is sent and copies of the replies to the clarifications sought shall be communicated to all those who have purchased the tender documents without identifying the source of the query and upload such clarification to the designated website for the information of those who have downloaded the tender documents from the website, without identifying the source of the query. (c) The amendments will be notified through corrigendum posted on the website Such amendments will form part of the tender document. Bidders are advised to constantly watch for any corrigendum at the above mentioned web address. (d) The Tender Inviting Authority reserves the right to extend the deadline for submission of tender for any reason, and the same shall be notified through corrigendum posted on the website 6. PRE-BID MEETING i. A Pre-Bid meeting of the prospective bidders will be held at 11 AM on 14 th Nov 2011( )in the Conference Hall of Health Department in the 4 th floor of the Secretariat, Fort St George, Chennai-9 to clarify any queries the Bidders may have, and for providing additional information if any. No separate intimation of the Pre-Bid meeting will be sent to the prospective Bidders unless there is a change in the time, date or venue of the Pre-Bid meeting, which will be posted on the websitewww.tenders.tn.gov.in. Maximum two authorized representative 7

8 of each interested Bidder will be allowed to attend the pre bid meeting. ii. A copy of the minutes of the Pre Bid meeting will be sent to all the prospective Bidders who attended the meeting and will be posted on the website: 7. DEADLINE FOR SUBMISSION OF BID : Completed Tender documents shall be received in the office of the Project Director, Tamil Nadu Health Systems Society, DMS Annexe Building, DMS Complex, Teynampet, Chennai-6 not later than 3 p.m. on 21st Nov Tender documents received later than the prescribed date and time shall not be opened and shall be returned unopened to the concerned Bidder. Delay due to postal or any other reason will not be condoned 8. PROCEDURE FOR EVALUATION OF BIDS AND AWARD OF CONTRACT. (i) The bids will be evaluated by a panel of officials nominated by Tender Inviting Authority. (ii) The technical bids will be opened on at 3.30 PM in the office of Project Director,Tamil Nadu Health Systems Society, DMS Annexe building, DMS campus, Chennai-6. Only one authorized representative of each Bidder will be allowed to attend. (iii) Once the technical bids have been evaluated, only the qualified Bidders will be informed about the date of opening of financial tenders and such financial tenders will be opened in the presence of the authorized representatives (maximum two per company) of each qualified Public Sector Insurance Company who chooses to be present. (iv) The lowest evaluated bidder will be eligible for the award of tender. 8

9 9. RIGHT TO NEGOTIATE AT THE TIME OF AWARD : The State Empowered Committee / Government of Tamil Nadu reserve the right to negotiate with lowest evaluated bidder after opening the Financial Bid. 10. RIGHT TO ACCEPT OR REJECT ANY OR ALL BIDS: The State Empowered Committee / Government of Tamil Nadu reserves the right to accept or reject any bid or cancel the tender process and reject all bids at any time without assigning any reason prior to the award of contract, without thereby incurring any liability to the bidders. The Tender Accepting Authority is not bound to accept the lowest evaluated bid or any other bids. 11. NOTIFICATION OF AWARD AND SIGNING OF AGREEMENT: The Notification of Award will be issued by the Tender Inviting Authority / Project Director, Tamil Nadu Health Systems Society with the approval of the Tender Accepting Authority. The terms of agreement are non-negotiable and the successful bidder shall sign the agreement which is found in Enclosure-4 in duplicate within 15 days of Notification of Award. 12. CONFIDENTIALITY: Information relating to the examination, clarification, evaluation, and comparison of bids, and recommendations for the award of contract shall not be disclosed to bidders or to any other persons not officially concerned with such process until the Notification of Award is made. 13. CANVASSING, FRAUDULENT AND CORRUPT PRACTICES: Bidders are hereby informed that canvassing in any form for influencing the process of notification of award would result in disqualification of the Bidder. Further, they shall observe the highest standard of ethics and will not indulge in any corrupt, fraudulent, coercive, undesirable or restrictive practices, as the case may be. 9

10 14. PERIOD OF AGREEMENT: (a) The agreement will be in force for a period of 4 years from the date of commencement of the Scheme, subject to annual renewal and extendable by one more year beyond 4 years with mutual consent. The renewal on yearly basis will be based on currency of IRDA license and a review of performance. (b) The Tamil Nadu Health Systems society shall have the right to cancel the agreement, if at any time during the period of the Scheme, the Public Sector insurance company defaults in delivery of services or it is found that it has misrepresented any fact during the tender process to attain qualification or breaches any of the conditions of the contract of Agreement. Chennai-6 Date: Project Director Tamil Nadu Health Systems Society Chennai

11 Enclosure 1 (i) G.O. (Ms)No.169,H&FW (EAP-II(2)) Department, Dated (ii) G.O. (Ms) No.189/H&FW (EAP-II(2)) Dept., dated (iii) G.O. (Ms) No.275/H&FW (EAP-II(2)) Dept., dated

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23 Enclosure 2 Chief Minister s Comprehensive Health Insurance Scheme Guidelines, Title These Guidelines may be called the Chief Minister s Comprehensive Health Insurance Scheme Guidelines, Application The Chief Minister s Comprehensive Health Insurance Scheme is launched to improve access of the poor families of Tamil Nadu, whose annual family income is less than Rs.72,000/- as certified by Village Administrative Officer to provide quality medical care for identified specialty services requiring hospitalization for surgeries and medical procedures as given in Annexure C, with provision to pay upto Rs 1.5 lakhs per year per family for certain specified procedures as per Annexure D and follow up services as per Annexure E and Diagnostic services as per Annexure F to the Guidelines in any of the empanelled hospitals subject to package rates on cashless basis through Health insurance card or Ration Card. 3. Definitions In these Guidelines, unless the context otherwise required,- (a) Eligible person means a member of a family whose annual family income is less than Rs.72,000/- as certified by Village Administrative Officer and such other person who may be declared to be eligible for coverage under the Chief Minister s Comprehensive Health Insurance Scheme by the Government (b) Entitlement means to provision of coverage up to Rs. 1 lakh per family per year as per Annexure C, with provision to pay upto Rs 1.5 lakhs per year per family for certain specified procedures as per Annexure D and follow up services as per Annexure E and Diagnostic services as per Annexure F to the Guidelines in any of 23

24 the empanelled hospitals subject to package rates on cashless basis through Health insurance card or Ration Card. (c) Family includes the eligible member, and the members of his or her family as detailed below: (i) legal spouse of the eligible person; (ii) Children of the eligible person till they get employed or married or attain the age of 25 years, whichever is earlier, and who are dependent on the eligible person; (iii) Dependent parents of the eligible person. Provided that if any person, in any of the categories at (i), (ii) or (iii) above, finds place in the family ration card, then it shall be presumed that the person is member of the family, and no further confirmation would be required. (d) Government means Government of Tamil Nadu. (e) Guidelines means the Chief Minister s Comprehensive Health Insurance Scheme Guidelines, (f) Hospital means any institution established for inpatient medical care with sufficient facilities for the disease treatment and surgeries which would fulfill the criteria under Clause 8 of Guidelines below and which has been included, in the approved network of hospital by the successful Bidder. (g) Scheme means the Chief Minister s Comprehensive Health Insurance Scheme ordered in G.O.(Ms) No.169, H&FW (EAP- II(2))Dept., dt , along with provisions included in the Government Order and further amendment to this Government Order (h) Third Party Administrator means an organization, as defined and licensed under the Insurance Regulatory and Development Authority, (Third Party Administrators Health Services) Regulations, 2001, and is engaged for a fee or remuneration by an Public Sector insurance company for the provision of health services. 24

25 4. Objectives The main objective of the Scheme is to provide free medical and surgical treatment in Government and Private hospitals to the members of any family whose annual family income is less than Rs.72,000/-, as certified by the Village Administrative Officers. 5. Scope of the Scheme. The Scope of the Scheme shall be to provide coverage as per entitlement for the eligible expenses incurred by the eligible person on behalf of himself or any member of his or her family for the treatment of procedures listed in the Annexure C,D,E,F and G to the Guidelines. The coverage will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, food to inpatient, transport cost etc., transport cost restricted to a maximum of Rs.1000/- per year. Expenses incurred for diagnostic test and medicines upto 1 day before the admission of the patient and cost of diagnostic tests and medicine upto 5 days of the discharge from the hospital for the same ailment/ surgery including transport expenses will also be the part of the package. In instance of death the carriage of dead body from the networked hospitals to the village / township/city would also be the part of the package. In addition, for the identified 120 procedures listed in annexure E to the guidelines, and coverage will be provided for the extended period of time as a separate package. The number of procedures covered under the scheme may be modified with mutual consent, with the approval of State Empowered Committee. 25

26 Project Director, Tamil Nadu Health Systems Society reserves the right to reserve certain procedures for the Government hospitals as per annexure G which is a tentative, illustrative list. This list can be modified any time by Tamil Nadu Health Systems Society. 6. Diagnostic procedures a) The diagnostic procedures leading to surgery / medical management under this insurance scheme will be part of the package. b) For the patients referred through Government facility who require to undergo further diagnostic procedures specified in annexure F to the guidelines, at the empanelled hospitals, the cost for the diagnostic procedures will be reimbursed as a separate package cost, even if those diagnostic procedures do not lead to an approved procedures for surgery / medical management under the scheme. For the patients referred through the screening camps of the private hospitals who require to undergo further diagnostic procedures specified in annexure F to the guidelines, if not leading to an approved procedures for surgery / medical management under the scheme, the cost for the diagnostic procedures shall be borne by the private hospitals themselves and shall not be charged on the patients. This facility is also not available to the patients who are directly approaching the private hospitals without referral / screening camps. 7. Empanelment and Disciplinary Committee- The committee under the chairmanship of Project Director, Tamil Nadu Health System Society with one member from Public Sector Insurance company and officials from State Health Insurance Unit in the Tamil Nadu Health System Society to empanel and regulate the functioning of the network hospitals under this scheme. 8. Hospitals to be covered under the Scheme. (1) The Hospitals under the Scheme shall include both Government and private hospitals. A hospital shall be qualified and tied up as a networked 26

27 hospital by the successful bidder with the approval of Empanelment and Disciplinary Committee only if it complies with the minimum criteria as under. (a) It should have at least 30 inpatient beds. Exemption may be given by Empanelment and Disciplinary Committee for single-specialty hospitals and in remote areas. (b) It should be equipped and engaged in providing medical and surgical facilities along with diagnostic facilities i.e. Pathological tests, X-ray and other investigations like Electro Cardiograph etc., for the care and treatment of injured or sick persons as in-patients; Provided that hospitals may get diagnostic tests done through established diagnostic centers outside the hospital; (c) It should have a fully equipped operation theatre of its own wherever surgical operations are carried out; (d) It should have qualified doctor(s) and nurses, physically in charge round the clock; (necessary certificates to be produced during empanelment) (e) It should maintain complete records as required on day to day basis and be able to provide necessary records of the insured patient to the successful bidder,project Director, Tamil Nadu Health Systems Society or their representatives as and when required; (2) The successful bidder shall ensure the availability of, excluding Government Hospitals, a minimum of 50 networked hospitals in the district of Chennai, 20 networked hospitals each in the districts of Coimbatore and Madurai, 6 networked hospitals each in other districts of the State and the availability of a minimum 50 networked hospitals in the areas under each district cluster as indicated below: (a) Northern Cluster: Cuddalore, Kancheepuram, Tiruvallur, Tiruvannamalai, Vellore and Villupuram. 27

28 (b) Central Cluster: Ariyalur, Karur, Nagapattinam, Perambalur, Pudukottai, Thanjavur, Tiruchirapalli and Tiruvarur. (c) Western Cluster: Dharmapuri, Erode, Krishnagiri, Namakkal, Salem, Tiruppur and The Nilgiris (d) Southern Cluster: Dindigul Kanyakumari, Ramanathapuram, Sivagangai, Theni, Tirunelveli, Tuticorin and Virudhunagar. (3) The Public Sector Insurance Company approved by the Government to implement this Insurance Scheme shall do the Empanelment of Hospitals including required number of stand alone diagnostic centers with approval of Empanelment and Disciplinary Committee by following the standard prescribed for the hospitals with regard to the availability of physical facilities, equipments for diagnoses / treatment and the qualified specialists and other staff for the diseases identified for the assistance. (4) If any district or cluster does not have the number of hospitals as specified above, the successful Public Sector insurance company can seek specific exemption for that district or cluster and the same will be considered by the Project Director, Tamil Nadu Health Systems Society, after verification of the available qualified hospitals in that district or cluster. (5) Few institutions (excluding Government Hospitals) situated at Puducherry, Bengaluru, chitoor, Cochin, mysore and Thiruvanthapuram shall also be included in the list of eligible hospitals with the approval of Empanelment and Disciplinary Committee. (6) The successful bidder, at any time of the implementation of the scheme, may add any hospital to the approved list of hospital, after getting 28

29 concurrence of the Empanelment and Disciplinary Committee provided the hospital satisfies the conditions given in Clause 8 of the Guidelines. (7) Where any fraudulent claim becomes directly attributable to a Hospital included in the networked hospitals, the hospital shall be removed and excluded under the Scheme by Empanelment and Disciplinary Committee. 9. Sum insured on Family Floater Basis (1) The Scheme shall provide coverage for the treatments as defined in Clause 5, of Guidelines as per Entitlement for 4 years from the date of commencement of the Scheme in any of the empanelled hospitals. (2) If any member of the family of an eligible person is eligible to have his name included in the family of an another eligible person, he would be eligible to have his name included in one health insurance identity card only and claim assistance under one card only; (3) The benefit will be on floater basis and can be availed of individually or collectively by members of the family during the policy year with no restriction on the number of times the benefit is availed. The unutilized Entitlement will lapse at the end of every policy year. 10. Health Insurance identity Card (1) A new Health Insurance identity card, a smart card with micro processor chip, containing Bio-Metrics and photographs of all the members for identification of beneficiary shall be generated using the existing data base which has to be compatible with UID and ration cards and distributed through the successful bidder. The new enrollment and issue of cards will be through district kiosk to be established by the Public Sector insurance company. (2) The Health Insurance Identity card cost shall be separated from the premium amount and the card cost is fixed at Rs. 50/-. This cost will be paid to the Public Sector insurance company on receipt of acknowledgment and verification of the distribution of the cards to the beneficiaries. 29

30 (3) Card Operating System shall comply to SCOSTA standards ver. 1.2b with latest addendum and errata. (refer web site The Smart Cards to be used must have the valid SCOSTA Compliance Certificate from National Informatics Center, New Delhi (refer SCOSTA Card Specification: o Microprocessor based Integrated Circuit(s) card with Contacts, with minimum 64 Kbytes available EEPROM for application data. o Compliant with ISO/IEC ,2,3 o Compliant to SCOSTA 1.2b Dt. 15 March 2002 with latest addendum and errata o Supply Voltage 3V nominal. o Communication Protocol T=0 or T=1. o Data Retention minimum 10 years. o Write cycles minimum 100,000 numbers. o Operating Temperature Range 25 to +55 Degree Celsius. o Plastic Construction PVC or Composite with ABS with PVC overlay. o Surface Glossy. (4) Wherever necessary the successful bidder with the concurrence of the Project Director, Tamil Nadu Health System Society can seek the assistance of i) The Village Administrative Officers in Rural Areas, and ii) Bill collectors of Urban Local Bodies in Urban Areas, or iii) any other authority. (5) Format for acknowledgement of distribution of Health Insurance Identity Card Sl. No. Smart card No. Name of the beneficiary Address of the beneficiary Village name Taluk name Ration card No. Signature Thumb impression

31 The above is the format for acknowledgment. On receipt of the acknowledgement it is subject to verification by an authorized official by the Tamil Nadu Health Systems Society. (6) The health insurance identity cards shall be made available within a period of Sixty days from the date of award or the date of handing over the data of the beneficiaries, whichever is later. (7) During the interim period of preparation and distribution of the health insurance identity cards, the successful bidder shall authorize preauthorization for treatment based on the ration card and the income certificate issued by the Village Administrative Officers after verifying with the existing database. (8) The expenditure on the preparation of health insurance identity cards and new enrolments made in the district kiosks, should be borne by the successful bidder and the Government or the Tamil Nadu Health Systems Society would not be liable for separate payment for this activity (9) The data furnished by the State Government or Project Director, Tamil Nadu Health Systems Society, shall be the property of the State Government / Project Director, Tamil Nadu Health Systems Society, and should not be used for any other purpose without the prior permission of the Government of Tamil Nadu or the Project Director, Tamil Nadu Health Systems Society, as the case may be. (10) All software utilized including the application software and new data generated during the implementation of the scheme will be the property of the society and shall be handed over to the society with source code. 31

32 11. Implementation Procedure. (1) The Scheme will be implemented by the State Health Insurance Unit, Tamil Nadu Health Systems Society, Chennai and the premium payable will be released through the Tamil Nadu Health Systems Society. (2) The suitable successful bidder for implementation of the scheme will be selected through national competitive bidding. (3) The Scheme may also be administered through the Third Party Administrators. The Third Party Administrator, if any, implementing the scheme on behalf of the successful bidder should also be an agency approved by the Insurance Regulatory and Development Authority. The successful bidder would be required to have, within one month of signing the agreement, offices for processing claims in all districts of Tamil Nadu. The details of Third party Administrator(s), if any, or branches of the successful bidder shall be furnished within one month from the date of signing the agreement. (4) The selected successful bidder shall sign Agreement with the empanelled hospitals under the scheme (both Government and private hospitals). The successful bidder, at any time of the implementation of the scheme, may add, suspend or remove any hospital to the list of network hospital, after getting concurrence of the Empanelment and Disciplinary Committee, provided the hospital satisfies the conditions given in Clause 8 of Guidelines. (5) The Government of Tamil Nadu will provide the basic details of eligible person and his or her family members to be covered under the Scheme, viz. numbering about 1.34 crores families (approximately) with average enrolled family size of 2.7 persons to the selected successful bidder immediately after signing of the agreement. 32

33 (6) The successful bidder shall prepare and distribute the health insurance identity cards as per clause 10 of the guidelines. (7) The successful bidder shall ensure that the members of the family of eligible persons are treated without having to make any cash payment. Successful bidder shall publish, locally and on the website, the likely cost for each procedure in a particular hospital, to enable the enrolled member to choose the appropriate hospital for treatment. Provided further that the Hospital shall give a rough estimate to the patient on the likely expenditure before he is admitted. (8) The successful bidder shall furnish a daily report on the pre authorization given, claims approved, amount disbursed, procedure/specialty wise and district wise etc to the Project Director, Tamil Nadu Health Systems Society in addition to the specific reports as and when required. (9) The Hospital will raise the bill on the successful bidder. The successful bidder shall process the claim and settle the claims expeditiously so as to ensure that the Hospitals provide the services to the beneficiaries without fail. The Tamil Nadu Health Systems Society will reserve the right to monitor the claim processing through software and the facility should be provided by the successful bidder in this regard. In case of any failure in services from the Hospitals due to pending bills, the successful bidder will be held responsible. (10) The Scheme shall commence on a date to be notified. (11) The scheme will be implemented as per the agreement in Enclosure Payment of Premium. (1) The Project Director, Tamil Nadu Health Systems Society, will pay the insurance premium on behalf of the eligible persons to the successful bidder. 33

34 (2) The premium would be paid every year in four quarterly installments on or before the first day of the quarter every year, with the year being reckoned from the date of commencement of the Scheme. (3) The first premium for the first year of the scheme would be paid on or before the date of commencement of the scheme. The amount of premium would be arrived as twenty-five percent of the premium payable based on the number of eligible persons provided to the successful bidder by the Tamil Nadu Health Systems Society, on or before the date of commencement of the scheme. For the subsequent quarters, insurance premium will be released based on the number of health insurance cards issued. (4) In case a member is enrolled in the middle of the year, only proportionate premium shall be paid. 13. Refund. - After providing 20% of the premium paid towards the companies administrative cost, if there is any surplus after the claims experience on the premium (excluding service tax) at the end of the policy period, of the balance 80% after providing for outstanding claims if any, 90% of the leftover surplus will be refunded to the society within 30 days after the expiry of the policy year. If the claims experience on the premium is more than 100%, the excess above 100% may be compensated from out of the refunded amount remitted by the Public Sector insurance company in the block of 4 years. Say for example if the premium amount is Rs.100/- Rs.20/- goes to company s administrative cost. Rs.80/- is now leftout. If the claim amount is Rs.50/- Rs.30/- is then the leftover amount. 34

35 Out of Rs.30/-, Rs.27/- (90% of Rs.30/-) is to be refunded back to the society within 30 days after the expiry of the policy year. Say for example if the claim is 110% Out of the refunded Rs.27/-, the society will compensate Rs.10/- to the insurance company. If the claim is 150% Since the refunded amount is only Rs.27/-, the society will compensate only Rs.27/- and not Rs.50/. 14. Performance monitoring. Performance of the Successful bidder will be monitored regularly based on the following Parameters Timely preauthorization Timely claim settlement Complaints redressal Claim ratio Number of health camps conducted in a month Any other parameters. 15. Online Management Information System (MIS and 24 Hours Preauthorization. The Public Sector Insurance Company should post enough dedicated staff, so as to ensure free flow of daily MIS and ensure that progress of scheme is reported to society in the desired format on a real-time basis. The company should establish proper networking for quick and error-free processing of preauthorizations. The pre-authorization has to be done round the clock which will be scrutinized by Tamil Nadu Health Systems Society periodically and preauthorization shall be done within 24 hours. A provision for emergency intimation and approval should also be established. In instance of dispute, the 35

36 final decision on preauthorization rest with the Project Director of Tamil Nadu Health Systems Society. The preauthorization team shall have all the specialists concerned with the procedures covered in the scheme on a permanent basis. 16. Capacity Building & IEC: The successful bidder shall arrange workshops and carry out publicity satisfying the need for the capacity building of the insured and implementers, at each district according to the need as decided by Project Director of Tamil Nadu Health Systems Society. 17. PUBLICITY: The successful bidder on its part should ensure that proper publicity is given to the scheme in all possible ways. This will include publicity on electronic and print media, distribution of brochures, banners, display boards etc. in public at appropriate places in consultation with Project Director, Tamil Nadu Health Systems Society. They shall also effectively use services of Liaison Officer and district Coordinators for this purpose. 18. Health camps / Screening camps Successful bidder shall ensure that, free health camps / screening camps by network hospitals are to be conducted as per the directions given by Project Director of Tamil Nadu Health Systems Society. Minimum of one camp per month per empanelled hospital has to be held in the districts in each policy year. Network hospital shall carry necessary screening equipments along with specialists (as suggested by the Tamil Nadu Health Systems Society) and other Para-medical staff. The empanelled hospital shall work in close liaison with, Dean, Joint Director of Health Services, Deputy Director of Health Services and District coordinator of the Public Sector Insurance Company in consultation with District Collector 36

37 19. Liaison Officer The successful bidder needs to appoint at least one Liaison Officer at all network hospitals to facilitate admission, treatment and cashless transaction to the patient. The Liaison Officer should also help hospitals in preauthorization, claim settlement and follow-up. They should also ensure proper reception and care in the hospitals and send regular MIS to call center. Successful bidder shall provide all Liaison Officer with cell phone having CUG connectivity with SMS based reporting framework for effective and instant communication. The role of Liaison Officer can be modified by State Empowered Committee from time-to-time. The bidder will provide uniform and arrange the workshops/training sessions for the Liaison Officer specified by Project Director, Tamil Nadu Health Systems Society. 20. District level co-ordination: District level offices with necessary infrastructure have to be set-up by the successful bidder. The bidder needs to have sufficient monitoring staff with District Coordinators & State Coordinators. They should monitor Liaison Officers to be appointed by the successful bidder in each networked hospitals, coordinate with network hospital, district administration and people s representatives for effective implementation of the Scheme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiary families. They should work in close liaison with district administration under the supervision of District Collector. They should also ensure proper flow of MIS and report to Project Director, Tamil Nadu Health Systems Society on day to day basis about the progress of the scheme in the district. The successful bidder should ensure that dedicated staff is made available for the scheme. They shall follow the instructions of State Empowered Committee / Tamil Nadu Health Systems Society in this regard. 37

38 21. Settlement of Claims. The claims have to be settled within 7 days of receipt of all reports, bills & the satisfaction report of the beneficiary. 22. Medical Auditors: The successful bidder shall appoint enough number of medical auditors, who scrutinize preauthorization. The bidder shall also recruit specialized doctors for regular inspection of hospitals, attend to complaints from beneficiary families directly or through Liaison Officer or from Project Director, Tamil Nadu Health Systems Society for any deficiency in services by the hospitals and also to ensure proper care and counseling for the patient at network hospital by coordinating with Liaison Officer and hospital authorities. 23. Website and Call Centers: (1) The successful bidder shall set up a dedicated website for the Scheme to enable people to have access to information on the scheme and correspond. (2) The successful bidder shall set up a 24 hour call centre at TNHSP office with sufficient manpower as per Project Director, TNHSP directions with toll free help line and all the telephonic conversation to be recorded and submitted for the scrutiny by the Tamil Nadu Health Systems Society. 24. Manual. The successful Bidder will publish a detailed Manual for the Chief Minister s Comprehensive Health Insurance Scheme with all operational guidelines and details of the scheme in consultation with Tamil Nadu Health Systems Society, with provision to update and modify. The insurer shall follow the guidelines and instructions given in the manual while implementing the scheme. 25. Penalty i) Deficiency in services Failure to provide services as required by terms of Scheme in the tender document will attract penalty as may be determined by 38

39 the Project Director, Tamil Nadu Health Systems Society, subject to the minimum of five times the amount of the expenditure incurred by the Government of Tamil Nadu / Project Director, Tamil Nadu Health Systems Society, or beneficiary due to non compliance. ii) Non adherence of time line - Failure to adhere to Activity Chart as per the Annexure A in Guidelines will attract the Penalty as may be determined by the Project Director Tamil Nadu Health Systems Society subject to maximum of one percent of premium payable for each occasion. iii) Failure to process pre-auth with in 24hrs from the time of submission will attract the Penalty of payment of expenditure incurred by the hospital towards the treatment of patient. iv) Failure to settle claims with in a week from the time of submission will attract the Penalty of payment of expenditure incurred by the hospital towards the treatment & extra stay of patient with 18% interest cumulative. v) In addition to that, fine will be levied by the Project director, TNHSP up to 1% in the premium amount on each occasion on failure of processing pre-auth & claims settlement within the stipulated time. 26. Redressal of grievances. (1) Any complaints about any difficulty in availing treatments, nonavailability of facilities, bogus availing of treatment for ineligible individuals, etc., shall be submitted to the District Collector, Deputy Director of Health Services and Joint Director of the Medical and Rural Health Services for necessary action or to the call centre established at Tamil Nadu Health Systems Project. (2) The complaints received shall be placed for decision of a District Monitoring and Grievance Committee at District level headed by the District 39

40 Collector, having the Dean/medical superintendent of the medical college, Joint Director of Medical and Rural Health Services Department, Deputy Director of Health Services and the representative of the Public Sector Insurance Company as members and Special Deputy Collector (SSS) as member secretary. (3) Any grievances and appeal against the decision of the District Monitoring and Grievance Committee may be preferred to the State Monitoring and Grievance Committee consisting of the Project Director, Tamil Nadu Health Systems Society, as Chairperson, and having the Director of Medical Education, Director of Medical and Rural Health Services, Director of Public Health and official representative nominated by the successful bidder as member. The decision of the committee is final. (4) The Civil Courts situated in Tamilnadu shall have exclusive jurisdiction over any disputes, which remain unresolved by the above procedure. (5) Nothing aforesaid, shall prejudice the rights of the Government of Tamil Nadu or Tamil Nadu Health Systems Society to approach any other forum for dispute resolution permissible under Law. Chennai-6 Date: Project Director Tamil Nadu Health Systems Society Chennai

41 ANNEXURE-A ACTIVITY CHART Number of days required to Activity complete the activity from the award date* Identifying the Project Officer 7 days Setting up of Project Office with 15 days infrastructure in the area of Municipal Corporation of Chennai Appointment of staff including doctors 20 days Empanelment of hospitals, appointment of 30 days Liasion officers and identification of DMO (Dedicated medical officer) and MCC (medical camp coordinator) Installation of kiosk, computer and 15 days Accessories, CUG connections and 1mbps connectivity in the offices and hospitals. Printing and distribution of publicity 15 days Material and workflow Training of Staffs including Doctors 10 days IT enabling 20 days Establishment of 24 Hrs Call Center 15 days Establishment of other infrastructure 25 days Establishment of district kiosk and other 20 days infrastructure in the districts Preparatory meetings and trainings at district 20 days level for inaugural mega camps. * Each activity starts from the day of signing of agreement DATE: SIGNATURE Stamp: Name: Designation: Address: Remarks 41

42 ANNEXURE-B Details of the Hospitals covered under the Scheme Districts Name of Hospital With contact details like phone, address and etc including the contact details of persons like Owner, DMO, MCC Details of the operating doctors /Physicians with Medical registration number Empanelled for specialized category/ies and procedures DATE: SIGNATURE Stamp: Name: Designation: Address: 42

43 Annexure : C The List of Surgeries / Therapies to be covered under the Chief Minister s Comprehensive Health Insurance Scheme CARDIAC AND CARDIOTHORACIC SURGERY S.No SYSTEM CARDIAC INTERVENTIONS / PROCEDURES 1 CORONARY BALLOON ANGIOPLASTY 2 PTCA with baremetal stent 3 Additional Stent 4 ASD Device closure 5 VSD Device closure 6 PDA Stenting 7 Device closure 8 Single coil 9 Multiple coils 10 BALLOON VALVOTOMY 11 Balloon Atrial septostomy 12 PERMANENT PACEMAKER IMPLANTATION 13 TEMPORARY PACEMAKER IMPLANTATION 14 With stent 15 Without stent 16 Additional Stent 17 RENAL ANGIOPLASTY 43

44 18 Peripheral Angioplasty 19 VERTEBRAL ANGIOPLASTY CARDIOTHORACIC AND VASCULAR SURGERIES 20 CORONARY BYPASS SURGERY 21 CORONARY BYPASS SURGERY-POST ANGIOPLASTY 22 CABG WITH IABP PUMP 23 Coronary bypass Surgery off pump with IABP 24 CABG of pump without IABP 25 CABG WITH ANEURISMAL REPAIR 26 MITRAL VALVE REPLACEMENT (WITH VALVE) 27 AORTIC VALVE REPLACEMENT (WITH VALVE) 28 TRICUSPID VALVE REPLACEMENT 29 DOUBLE VALVE REPLACEMENT (WITH VALVE) 30 COARCTATION-AROTA REPAIR WITH GRAFT 31 COARCTATION-AROTA REPAIR WITHOUT GRAFT 32 ANEURYSM RESECTION & GRAFTING INTRATHORACIC ANEURYSM -ANEURYSM NOT REQUIRING BYPASS INTRATHORACIC ANEURYSM -REQUIRING BYPASS (WITH GRAFT) 35 DISSECTING ANEURYSMS 36 AORTO-AORTO BYPASS WITH GRAFT 37 ANNULUS AORTIC ECTASIA WITH VALVED CONDUITS 38 AORTO-AORTO BYPASS WITHOUT GRAFT 39 FEMORO- POPLITIAL BYPASS WITH GRAFT 44

45 40 FEMORO- POPLITIAL BYPASS WITHOUT GRAFT 41 FEMORO-ILEAL BYPASS WITH GRAFT 42 FEMORO -ILEAL BYPASS WITH-OUT GRAFT 43 FEMORO-FEMORAL BYPASS WITH GRAFT 44 FEMORO-FEMORAL BYPASS WITHOUT GRAFT 45 Arterial Switch 46 Sennings Procedure 47 Carotid Embolectomy 48 SURGERY FOR INTRACARDIAC TUMORS 49 RUPTURED SINUS OF VALSULVA CORRECTION 50 TAPVC CORRECTION 51 SYSTEMIC PULMONARY SHUNTS WITH GRAFT 52 SYSTEMIC PULMONARY SHUNTS WITHOUT GRAFT 53 TOTAL CORRECTION OF TETRALOGY OF FALLOT 54 INTRA CARDIAC REPAIR OF ASD 55 Intracardiac Repair of VSD 56 Surgery-PDA 57 WITH SPECIAL CONDUITS 58 WITHOUT SPECIAL CONDUITS 59 WITH PROSTHETIC RING 60 WITHOUT PROSTHETIC RING 61 OPEN PULMONARY VALVOTOMY 62 CLOSED MITRAL VALVOTOMY 63 PERICARDIOSTOMY 45

46 64 PERICARDIECTOMY 65 PERICARDIOCENTESIS 66 MITRAL VALVOTOMY (OPEN) LUNGS 67 PNEUMONECTOMY (only for abscess) 68 LOBECTOMY (only for abscess) 69 DECORTICATION 70 LUNG CYST 71 SOL MEDIASTINUM 72 Thorocoplasty 73 Myoplasty 74 TRANSPLEURAL BPF CLOSURE CARDIAC INJURES 75 SURGERY WITHOUT CPB 76 SURGERY WITH CPB 77 Primary angioplasty for acute MI +Drug Eluting stent 78 Additional Stent required 79 Enhanced External Counter Pulsation Therapy (EECP) SURGICAL ONCOLOGY HEAD & NECK 80 COMPOSITE RESECTION & RECONSTRUCTION 81 WIDE EXCISION 82 HEMIGLOSSECTOMY 83 MAXILLECTOMY ANY TYPE 46

47 84 THYROIDECTOMY ANY TYPE 85 PAROTIDECTOMY ANY TYPE 86 LARYNGECTOMY ANY TYPE 87 LARYNGOPHARYNGO OESOPHAGECTOMY GASTROINTESTINAL TRACT 88 OESOPHAGECTOMY ANY TYPE 89 COLECTOMY ANY TYPE 90 WHIPPLES ANY TYPE 91 TRIPLE BYPASS 92 Other Bypasses-Pancreas GENITO URINARY SYSTEM 93 RADICAL NEPHRECTOMY 94 EMASCULATION 95 RADICAL CYSTECTOMY 96 OTHER CYSTECTOMIES 97 INGUINAL BLOCK DISSECTION ONE SIDE 98 RADICAL PROSTATECTOMY 99 HIGH ORCHIDECTOMY 100 BILATERAL ORCHIDECTOMY GYNAECOLOGICAL ONCOLOGY 101 HYSTERECTOMY 102 RADICAL HYSTERECTOMY 103 SURGERY FOR CA OVARY EARLY STAGE 104 SURGERY FOR CA OVARY ADVANCE STAGE 47